In-depth Assassment of Client Substance Use

At the point where a concern is raised, in-depth assessment of a client's drug or alcohol use is conducted with two related purposes. First, the assessor collects information to determine whether the client's substance use and related behaviors meet the diagnostic criteria for abusive, dependent, or otherwise disordered consumption.

In general terms, diagnosis involves critical analysis to determine the nature and cause of a disorder through

examination of the patient history and relevant clinical data. The DSM-IV (American Psychiatric Association, 1994, 2000) criteria are among the most widely utilized frameworks for diagnosing substance use disorders, and are thus presented next as guidelines for assessment. The criteria for substance use disorders were not changed in the 2000 Text Revision of the DSM-IV. If in fact the assessment supports the conclusion that the client is at risk of developing or already exhibiting a substance use disorder, the second purpose of assessment is to determine the appropriate level and format of recommended treatment, setting the stage for the development of a treatment plan (to be covered in chap. 6).

With these purposes of diagnosis and placement in mind, the assessor is encouraged to also build rapport with the client in efforts to engage the client in the assessment interview. The assessor who can connect on an affective level with the client and share the client's story is better able to motivate the client to consider the treatment recommendations the assessor makes toward the end of the assessment interview.

DSM-IV Diagnostic Categories of Substance Use Disorder

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, American Psychiatric Association, 1994, 2000) classifies disorders directly related to psychoactive substances into four general categories: Intoxication, Withdrawal, Abuse, and Dependence. Substance Abuse and Dependence are both considered disorders of substance use behavior, whereas Intoxication and Withdrawal are among the syndromes that can be induced by exposure to or ingestion of substances including illicit drugs, alcohol, medications, or toxins. To a certain extent, each of the four general categories of substance-related disorders can be manifest by users of various different substances, which allows for conceptualization and documentation of the common factors among substance-related disorders. In addition to these four general diagnostic categories, the DSM-IV offers further specification of characteristics that indicate disordered use or induced syndromes connected with each class of substances. The DSM-IV identifies eleven classes of abused substances and associated disorders. These classes consist of alcohol, amphetamines, caffeine, cannabis (marijuana), cocaine, hallucinogen, inhalant, nicotine, opioid, phencyclidine (PGP), and sedative/hypnotic/anxiolytic drugs.

Additional categories include polysubstance dependence and other or unknown substance-related disorders (covering steroids, nitrous oxide, and self-administration of prescription drugs, among others).

Proposed Template for In-Depth Substance

Use Assessment Interview

The template provided next can be used with clients who are new to the therapist or with clients the therapist knows well, but for whom substance use concerns have only recently emerged in session. The template organizes a structure the therapist can use to conduct a thorough substance use assessment, but it is by no means the only format available for this task (see e.g., Donovan and Marlatt, in press; Lewis, Dana, and Blevins, 2002;

McLellan, Luborsky, Woody, and O'Brien, 1980; McLellan et al., 1992; Ott and Tarter, 1998). Readers are encouraged to use this template flexibly, in accordance with their own experiences and with their places of employment or training. The important point is for assessors to be aware of the broad range of considerations to be addressed in piecing together a picture of the client's substance use issues. Confidentiality provisions and limitations should be addressed with the client prior to starting the assessment, and these are discussed in detail later in this chapter.

Introduction of the Assessment Process. For clients who have never taken part in a substance use assessment before, especially those clients who have attended reluctantly at best, the assessor should make an effort to

establish rapport and explain the process about to unfold. Even clients who have been through a prior assessment are more readily engaged in the immediate process if the assessor gives an idea of what will happen in the present session. Neutral terminology at the beginning can facilitate the interview. For example, with clients specifically requesting a substance use assessment, the assessor might say:

We're meeting today to assess your experience with alcohol and drugs. That means I'm going to ask you a set of standard questions I ask every client whenever we agree to do a substance use assessment. This way I can try to get a broad picture of your own use of drugs or alcohol and any related consequences.

The deliberate reference to "use" rather than "abuse" and "consequences" rather than "problems" is intended to avoid making presumptions about the client's reasons for coming and also to prevent triggering resistance in clients who do not consider their substance use either abusive or problematic. Any questions the client might have can be invited and answered up front. With clients in therapy who did not present with substance abuse issues or request substance use assessment, the therapist may take a different approach to introduce the in-depth assessment process. First, this includes explaining the reasons, including corresponding observations, for recommending the joint undertaking of assessment of the client's substance use and related experience.

For example:

You've made three or four references now to "getting high," and to me that is sounding like a big enough part of your life that it would be worth talking about more, if you're willing. I'm interested because I think finding out more about that part of your life would help us decide together if your drug use is related to any of the other concerns we have been talking about.

The therapist using this introduction will also be ready to hear and respond to the client's reactions to this proposal. Next, the assessor often describes the assessment process to the client in enough detail so the client knows what to expect. For clients who are agreeable to the assessment, this may be less crucial than with a reluctant client, but it still helps prepare the client and structure the discussion when the therapist describes what will happen. When the client is unconvinced of the need for substance use assessment, the therapist's description can emphasize taking a nonjudgmental stance to gather information that will be used to determine whether a focus on substance use issues is relevant to plans for continuing therapy. For example, the assessor might say:

I'd like to take at least part of our session this week or next to ask you a series of questions about substance use that may or may not be related to your own history, but will give us a broader picture of your own actual experience, past and present. By learning more about any role substance use may have played in your life and where you stand on the topic, I'm in a better position to either be convinced we don't need to talk more about your substance use, or to think about other options open to us.

Finally, the therapist invites the client's questions or other reactions to the assessment proposal, giving them full weight of consideration through discussion as needed. The therapist asks for the client's agreement to proceed according to a negotiated schedule. If the client is willing and there is time left in the immediate session, the therapist may launch right into the substance use assessment. If this topic arises toward the end of a session or if the client wants time to think about the prospect, an agreement can be formulated to resume the discussion at the beginning of the subsequent session. With clients who dismiss the need for further assessment of their substance use even after the therapist has made the request and offered a rationale, the therapist can honor the client's refusal and still hold open the possibility that the discussion may resurface at another time.

Client History of Substance Use

Once the client asks for or agrees to an assessment, a logical next step is to inquire about the client's history of involvement with alcohol and other drugs. The diverse backgrounds of clients who use drugs or alcohol necessitate detailed history of each individual client's substance use.

The assessment history begins with asking the client's reasons for seeking the assessment (Buelow and Buelow, 1998). The therapist should record the answer in the client's own words; if paraphrasing is needed, the therapist is recommended to read the written reason back to the client and negotiate the wording until the client agrees with the reason (s) included in the record. With clients presenting specifically for substance use assessment and with whom the therapist is meeting for the first or second time, much important content is typically revealed by how the client answers this question. For example, a client's report that his wife threatened divorce indicates the need for attention to relationship issues, a client frightened by frequent blackouts and tremors probably needs referral for medical consultation, and the client who says she was ordered by a judge to get assessed following a DUI incident alerts the therapist that consents for releasing information to third parties will be necessary. In addition, the client's reasons for seeking assessment often provide some initial information about the client's attitudes toward personal substance use, toward motivations for changing current habits, and toward engaging in therapy to promote such change.

Whether the client's attitude is compliant, sheepish, defeatist, defiant, dismissive, hostile, or some other variant, the assessor can maximize the client's cooperation by empathizing with the client's perspective and reasons. The therapist's communication of acceptance, understanding, or tolerance of the new client's fears or frustrations must of course be couched in a firm frame of therapeutic boundaries. In most basic terms, the therapist's implicit message is, "I hear what you're telling me and here's what I have to offer."

When the assessment is conducted in the context of substance abuse concerns raised during the course of therapy with a continuing client, the reasons for the assessment have most likely already been discussed during collaborative decisions to incorporate this in-depth assessment into the treatment strategy. Still asking the client to elaborate on his or her understanding of the reason for assessment at the start provides opportunities for the therapist to hear how the client is approaching the activity and also to clear up any possible confusion. Once reasons for the assessment are established, the therapist informs the client that a detailed list of commonly used and abused substances will be covered. The therapist may start assessing substance use history by saying something like,

I'm going to go through a list of drugs and other substances that are widely used and abused, and I want to find out if and when you have personally tried any of them. I'll start with alcohol, because as you probably know, that's one of the most common recreational substances.

For each category of substances, the assessor then asks if the client has ever used it. If the answer is affirmative, the rest of the questions are relevant as well. The assessor, interested in the frequency, intensity, and severity of any substance use by the client, can ask the following questions for each drug category the client admits using:

At what age or approximate date did the client first try that drug? How has the client's use increased or decreased over time? When was the period of heaviest use, and what was it like? How much and how often has the client used over the past month? And what was the date and amount of most recent use?

Obviously asking each of these questions for each category of substances can be time-consuming, especially with clients who have lengthy histories or who have used multiple drugs. However, such extensive histories help pinpoint the nature of the client's issues and the most appropriate treatment options. Assessment may take more than one session.

The assessor who shows interest in the client's full story also helps establish rapport. In circumstances where time is limited, the assessor can express this interest without necessarily hearing the whole story at once. For example, if the client continues at length or brings up important information toward the end of the session, the assessor can let the client know, "What you're telling me sounds very important, and we will definitely come back to it because I want to hear more about it." (Or, if referral is in order: " ... and I strongly encourage you to bring it up with the therapist you will be working with...") "But to make sure we cover what we need to get to today, let me first ask you about. ..." In these instances, the assessor should make note of the topic to ensure that further assessment and discussion are conducted when time permits.

The history assessment starts with alcohol both because it is a legal drug and one consumed by people in virtually every segment of society. Clients are sometimes put at ease by first discussing their experience, if any, with this "safe" substance. The type of alcohol a client drinks (wine coolers, beer, mixed drinks, straight liquor, etc.) should be determined. For each subsequent category, the assessor also inquires about and records information about the form in which the client has used the drug. For cannabis, as an example, the assessor should determine whether the user has ingested the marijuana by means of joints, pipes, bongs, blunts, brownies, hash, chew, or some other form. By the time the assessment reaches the category of central nervous system (CNS) stimulants or "uppers," the assessor will note that a few examples of that category (e.g., cocaine, Ritalin, methamphetamine) are included to generate further questioning if the client is unfamiliar with the general category.

The categories of sedative ("downer"), opiate (painkiller or analgesic), and hallucinogenic drugs also include examples that can be offered to prompt clients who may not be aware how the drugs they have consumed are classified or how those drugs operate on the brain. For example, a client who took a "roofie" (Rohypnol) pill given to her at a party, in search of a fun "high" at the time, may not know that the so-called "date rape"

drug depresses the CNS and creates a sedative effect on the body. This history-taking phase of assessment also provides opportunities, then, for the therapist to begin educating the client about the nature and biological impact of the drugs the client has ingested, inhaled, injected, or been curious about using. Many therapists discover that the education goes both ways: Clients experienced with substance use and effects can help therapists better understand the impetus for and effects of taking drugs in addition to extending a therapist's list of drugs to be assessed for along with their "street names."

Walking through the client's drug history will also yield encounters with signals of issues the therapist will wish to record and pursue if ongoing therapy is recommended. Some clients are quite willing to tell their stories to an attentive, caring therapist, and some end up sharing personal details they had not planned on discussing. Clients' descriptions of their initiations into drinking or drug use or of the forces encouraging their continuing use can uncover links to co-morbid symptoms or interpersonal, educational, or occupational concerns. The effective assessor will take careful note of such hints or details and encourage the client to use ongoing therapy as an opportunity to explore these issues more deeply. Even at this early stage, the therapist can offer recognition of a difficulty and hope of finding a better way to deal with it.

Once the substance use history is completed, the assessor often already has some diagnostic impressions. At the least, the assessor can narrow the focus from generalized substance-related disorders to consideration of

disorder (s) associated with a particular class of substances. Distinguishing among diagnostic sets depends on not only the drug that has been used, but also on the conditions under which the drug was used and the consequences of use. Thus, the rest of the assessment template offered here explores the physical, psychological, interpersonal, educational, vocational, financial, and legal factors linked to the client's drug or alcohol use.

The Client's Recovery Environment

The client's recovery environment is a crucial factor in terms of the forces that support or inhibit any efforts the client makes to change problematic behaviors. Environmental assessment using a format allows the therapist to identify any aspects of the client's situation that may threaten the client's safety, well-being, sobriety, or efforts toward change, and to make treatment recommendations accordingly. In addition, the assessor can determine strengths inherent in the client's environment that can be utilized to promote recovery. Discussion of both bolstering and limiting factors in the client's environment also helps establish rapport and hope, as well as further setting the stage for treatment planning. For example, consider a cocaine dependent client who has reported reasonable social supports and no residential or legal problems, but is facing extreme debt due to his expensive drug habit, complicated by the threat of job loss. The assessor can segue into treatment recommendations by saying something like,

It seems that improving your situation would involve addressing not only your cocaine use, but also the financial problems it's caused, and maybe also the problems at work. Luckily you feel you can count on some family and friends to support you, but I can also offer the option of working in therapy on how to cope with the complications in your life. In fact, the next time you come in could be used to flesh out a plan for using your time in therapy to deal with the things you see as problems.